Headache in Children
Summary
Headache is a common paediatric presentation. While parental anxiety inevitably focuses on brain tumours, >90% of chronic headaches are primary (Migraine or Tension-Type). Key differences from adults: Childhood migraines are often bilateral (frontal), shorter duration (2-4 hours), and associated with prominent GI symptoms (abdominal migraine). However, brain tumours are the most common solid tumour in children, so red flag vigilance (HeadSmart criteria) is essential. [1,2]
Clinical Pearls
The "School Headache": If a child has headaches every weekday afternoon but is fine on weekends and holidays, consider: > 1. Dehydration (strict toilet policies). > 2. Visual Refractive Error (eye strain). > 3. Bullying/Stress.
Alice in Wonderland Syndrome: A bizarre but benign migraine aura seen in children. The child perceives objects (or body parts) as shrinking (Micropsia) or growing (Macropsia). It is terrifying but harmless.
Occipital Headache: While frontal/temporal pain is common, strictly occipital headache in a child is a red flag for posterior fossa pathology (e.g., Chiari Malformation or Tumour) until proven otherwise.
Demographics
- Prevalence: 50% of children experience headache by age 7.
- Migraine: 10% prevalence. Before puberty M=F. Post-puberty F>M.
- Brain Tumour: Incidence 3 per 100,000 (Rare).
Primary Headaches
- Migraine: Cortical Spreading Depression (electrical wave) + Trigeminal sensitisation. Genetic component (70% fam hist).
- Tension: Muscular contraction / Stress response.
Secondary Headaches
- Raised ICP: Tumour mass effect or Hydrocephalus. Worse when supine (morning) as gravity doesn't drain venous blood.
- Sinusitis: Inflammation of frontal/maxillary sinuses.
Paediatric Migraine (ICHD-3 criteria)
A. At least 5 attacks. B. Duration 2 - 72 hours (shorter than adults). C. At least 2 of:
Tension-Type
Medication Overuse Headache
The "3-Minute Neuro Exam"
- Gait: Tandem walking (heel-toe). Tests Cerebellum (Medulloblastoma).
- Fundoscopy: Check for Papilloedema (blurred disc margins). Tests ICP.
- Eye Movements: Check for Squint (CN VI palsy) or Nystagmus.
- Coordination: Finger-nose test.
- Growth: Height/Weight (Craniopharyngioma causes growth arrest). Head Circumference (Hydrocephalus).
- Blood Pressure: Malignant Hypertension can cause headache/encephalopathy.
"HeadSmart" Red Flags (Refer for MRI)
Refer urgently if:
- Persistent morning headache/vomiting.
- Change in behaviour / school performance.
- Abnormal neurological exam (Ataxia, Squint, Papilloedema).
- Headache waking from sleep.
- < 4 years old.
Primary Care Workup
- Headache Diary: The gold standard diagnostic tool. Tracks triggers, frequency, and pattern.
- Optician: Rule out refractive error.
Management Algorithm
CHILD WITH HEADACHE
↓
RED FLAGS? / ABNORMAL EXAM?
┌─────────┴─────────┐
YES NO
↓ ↓
URGENT MRI PRIMARY HEADACHE
(2 Week Wait) (Diary x 4 weeks)
↓
DIAGNOSIS CONFIRMED
┌───────────────────┼───────────────────┐
MIGRAINE TENSION-TYPE MED OVERUSE
↓ ↓ ↓
ACUTE: LIFESTYLE: WITHDRAW
- Sleep - Hydration ANALGESIA
- Ibuprofen - Sleep
- Sumatriptan - Stress reduction
(Nasal >12y)
↓
FREQUENT? (>1/week)
↓
PROPHYLAXIS:
- Pizotifen
- Propranolol
Acute Treatment (The Attack)
- Sleep: The most effective treatment in children.
- Analgesia: Ibuprofen (10mg/kg) + Paracetamol (15mg/kg). Taken early (at onset).
- Triptans: Sumatriptan Nasal Spray (10mg/20mg) is licensed for age 12-17 years. Tablets are off-label.
- Anti-emetics: Ondansetron/Cyclizine if vomiting prohibits oral meds.
Prophylaxis
Consider if missing school or >1 attack/week.
- Pizotifen: 5HT antagonist. Safe. Side effects: Weight gain, Drowsiness.
- Propranolol: Beta-blocker. Avoid in asthma.
- Topiramate: Effective but risk of cognitive slowing ("Dopamax"). S/E: Weight loss, Tingling.
- Riboflavin (Vit B2): 400mg daily. Placebo-like safety profile, some evidence of efficacy.
- Status Migrainosus: Attack lasting >72 hours. Dehydration risk. Treat with IV fluids + IV Aspirin/Chlorpromazine.
- School Refusal: "Illness behaviour" and anxiety.
- Missed Diagnosis: Brain tumour survival relies on early diagnosis.
- Childhood Migraine: 50% remit during adolescence (especially boys). Girls often develop menstrual migraine.
- Brain Tumours: Survival improved significantly with "HeadSmart" awareness. 5-year survival varies by tumour type (e.g., Pilocytic Astrocytoma >90%, DIPG less than 1%).
Key Guidelines
| Guideline | Organisation | Key Recommendations |
|---|---|---|
| Headaches in less than 12s | NICE CG150 | Use headache diary. Do not scan "reassuring" headaches. |
| Brain Tumours | HeadSmart | Referral criteria for imaging. |
| Migraine | BASH | Guidelines on paediatric triptan use. |
Landmark Evidence
1. CHAMPS Study (NEJM 2017)
- Showed that Amitriptyline and Topiramate were no better than placebo for paediatric migraine prophylaxis. This has shifted practice towards lifestyle/nutraceuticals first.
Does my child have a brain tumour?
Because you asked, I have checked specifically for signs of raised pressure in the brain (looking at the back of the eyes and checking balance). These are completely normal. Brain tumours are incredibly rare and usually show these physical signs. His headache fits the pattern of "Migraine" perfectly.
But he vomits?
Migraine is a "whole body" event in children. The stomach stops working (gastric stasis) during an attack, leading to vomiting. This is typical for abdominal migraine.
Treatment Plan
- Water: Drink more at school.
- Diary: Keep a record for 4 weeks so we can spot triggers (cheese, chocolate, stress).
- Attack: Give Ibuprofen immediately when it starts—don't wait for it to get bad. Then send him to bed in a dark room.
Primary Sources
- NICE. Headaches in over 12s: diagnosis and management [CG150]. 2012.
- Powers SW, et al. Trial of Amitriptyline, Topiramate, and Placebo for Pediatric Migraine (CHAMPS). N Engl J Med. 2017.
- The Brain Tumour Charity. HeadSmart: Be Brain Tumour Aware. 2021.
Common Exam Questions
- Red Flag: "Waking from sleep with headache?"
- Answer: MRI Brain (Raised ICP).
- Diagnosis: "Visual distortion (Micropsia)?"
- Answer: Alice in Wonderland Syndrome (Migraine aura).
- Management: "Licensed triptan for 14yo?"
- Answer: Sumatriptan Nasal Spray.
- Examination: "Why check BP?"
- Answer: Hypertension can cause headaches.
Viva Points
- Abdominal Migraine: Recurrent episodes of central abdo pain, nausea, and pallor. Often family history of migraine. Evolves into headache migraine later in life.
- Pizotifen: Why do teenagers hate it? Weight gain. Propranolol is weight neutral.
Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists.